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Based on review of facility policy, review of the Emergency Department (ED) Logs, review of facility documentation, review of Emergency Medical Services (EMS) documentation, medical record review, and interviews, the facility failed to provide a Medical Screening Examination (MSE) for 1 patient (#1) who presented to the ED after a motor vehicle collision (MVC) of 30 ED patients reviewed.

The findings included:

Review of facility documentation revealed Patient #1 was transported to Hospital A's ED via Emergency Medical Services (EMS) on 9/8/19 after a MVC. Further review revealed upon arrival to the ED the patient was taken to an ED room where the ED staff and the ED Physician were waiting. Continued review revealed there was a discussion between the ED Physician and EMS regarding why the patient was transported to Hospital A instead of a Level 1 Trauma Center. Further review revealed EMS left Hospital A with Patient #1 and transported the patient to Hospital B. Continued review revealed Patient #1 had no medical record or MSE documented for the patient. Further review revealed Patient #1 was admitted to Hospital B for observation. Continued review revealed Hospital A was 4 minutes from the scene of the MVC and was the closest facility.

Interview with the Corporate Director of Risk Management at Hospital A on 9/25/19 at 12:00 PM, in the conference room, revealed the facility immediately completed a detailed investigation of the incident involving Patient #1. Continued interview revealed the facility developed and implemented a corrective action plan to achieve compliance with EMTALA requirements. The corrective action plan included:

1. EMTALA education was started on 9/12/19 to include ED Nursing Staff Team Members, ED Physicians, ED Mid-Level providers, and Registration Members.
* 100% of the ED Nursing Staff completed the education by 9/24/19. All new team members will complete the education during orientation.
* 100% of the ED Physicians completed the training by 9/24/19. Any newly credentialed ED Physician will complete the education prior to working in the ED.
* 100% of the ED Mid-Level providers completed the education by 9/24/19. Any newly credentialed ED Mid-Level provider will complete the training prior to working in the ED.
* 100% of the Registration Staff completed the training by 9/24/19. Any new Registration Team member will complete the education during orientation.

2. A meeting with the Local EMS leadership and the facility was conducted on 9/16/19 to review EMTALA obligations and responsibilities and to open communication between the EMS and the facility.
* Ongoing meetings between the facility and EMS will occur two months of each quarter to address any ongoing opportunities.

3. The Chief Medical Officer met with the ED Physician on 9/12/19 to review details of the event and to provide one on one EMTALA education to the involved provider.

4. The involved patient was not registered by the ED staff on 9/8/19. The patient was added to the ED Log on 9/13/19 (6 days later) for clarity that the patient presented to the ED by the EMS for treatment/stabilization on 9/8/19.

5. EMTALA compliance monitoring will be reported at the facility's Quality Assurance Performance Improvement (QAPI) meeting until 12/2019. If compliance is met at 100% for four consecutive quarters the monitor will be reevaluated.

Refer to A-2406.

Based on review of facility policy, review of Emergency Medical Services (EMS) documentation, review of Emergency Department (ED) Logs, medical record review, and interview, the facility failed to maintain an accurate ED Log for 1 patient (#1) who presented to the ED after a Motor Vehicle Collision (MVC) of 30 ED patients reviewed.

The findings included:

Review of facility policy "EMTALA," last revised 2/2017, revealed "...central log: a log maintained by [named facility]...each individual who comes to its Dedicated Emergency Department (DED) or any location on the facility property seeking emergency assistance...shall maintain EMTALA Central Logs, which identify the patients who have presented for services...Central Log shall include the patient's name and outcome and indicate whether the patient...refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was discharged..."

Review of an Emergency Medical Services (EMS) Patient Care Report dated 9/8/19 at 2:57 PM revealed Patient #1 arrived at Hospital A's ED and was taken to an ED treatment room. Further review revealed the patient departed Hospital A via EMS and was transported to Hospital B at 3:07 PM (10 minutes after arrival).

Review of the ED Logs revealed the patient was not listed on the ED central log dated 9/8/19.

Medical record review revealed no ED triage record or medical record for Patient #1 dated 9/8/18 at Hospital A.

Interview with the Corporate Director of Risk Management on 9/25/19 at 12:00 PM, in the conference room, confirmed Patient #1 was not listed on the ED central log and there was no medical record for the patient dated 9/8/19.

Refer to A-2406.

Based on review of facility policy, review of Emergency Medical Services (EMS) documentation, medical record review, and interviews, the facility failed to provide a Medical Screening Examination (MSE) for 1 patient (#1) who presented to the Emergency Department (ED) via EMS after a motor vehicle collusion (MVC) of 30 ED patients reviewed.

The findings included:

Review of facility policy "EMTALA," last revised 2/2017, revealed "...it is the policy...to provide an appropriate Medical Screening examination to individuals presenting at its Dedicated Emergency Department [DED] requesting examination or treatment of a medical condition, and to individual presenting on [named facility's] property requesting examination or treatment of an Emergency Medical Condition, and if one exists, either to stabilize the emergency condition or to transfer the individual appropriately and in conformity with legal and regulatory requirements..." Further review revealed "...campus: means the building, structures and public areas...facility property means the entire campus for each facility (includes facilities that are within 250 yards of the main [named] facility)...including sidewalks, parking lots and driveways..." Continued review revealed "...a medical screening is the process required to reach, within reasonable clinical confidence, the point at which it can be determined whether an Emergency Medical Condition exists. The scope of the examination must be tailored to the presenting complaint and the medical history of the patient. The process may range from a simple examination (such as brief history and physical) to a complex examination...a medical record documenting the history and physical examination...will be created to document the screening exam..."

Review of an EMS Patient Care Report dated 9/8/19 at 2:28 PM revealed EMS received a call related to a MVC involving Patient #1. Continued review revealed Patient #1 was found in the vehicle with a puncture wound to the right side of the neck with visible bleeding and multiple bruises and skin tears. Further review revealed the patient was transported to Hospital A with vital signs as follows: blood pressure (BP) 109/69; Pulse 113; Respirations 16; Oxygen Saturation 94%. Continued review revealed the patient's Glasgow Coma Scale score (score indicating the patient's level of consciousness) was 15, indicating the patient was alert and oriented. Continued review revealed "...upon arrival at ER [emergency room] nursing staff assigned us to room 10 but before we completely entered the room [ED Physician #1] entered and stated that he [the patient] was going to be transferred to a trauma center and that we should have never brought him [Patient #1] to [Hospital A]...before I could give report to nursing staff. Patient was never moved from our cot and a report was never even ask for or given to [ED] staff. We rolled patient out of ER still on our cot back to the ambulance and transported on to [Hospital B]...patient was transferred to nearest facility for care of symptoms, complaints...per patient request and was refused treatment by ER Dr. [doctor]...was transported on to [Hospital B]..." Further review revealed the site of the MVC was 1.4 miles from Hospital A and 26.2 miles from Hospital B.

Medical record review revealed no ED triage record or medical record for Patient #1 dated 9/8/18 at Hospital A.

Medical record review of an ED Triage at Hospital B dated 9/8/19 at 3:47 PM revealed Patient #1 was evaluated by the Trauma Team. Further review revealed "...arrived by EMS to acute care...restrained driver involved in single vehicle MVC [motor vehicle collusion] hitting light pole at approximately 25-30 MPH [miles per hour] with airbag [deployed]...LOC [loss of consciousness]...laceration to right side of neck, bruising noted to left chest wall and left abdomen area..." Continued review revealed the patient's vital signs were: BP 128/75; pulse 94; respirations 17; and Oxygen Saturation 94%.

Medical record review of an Admission H&P from Hospital B dated 9/8/19 at 3:42 PM revealed the patient was admitted with diagnoses including Concussion Injury to the Brain and Drug Induced Thrombocytopenia (low platelet count).

Medical record review of a Discharge Summary from Hospital B dated 9/9/19 at 3:45 PM revealed Patient #1 was admitted overnight for observation and then discharged home with follow-up care with his Primary Care Physician and Oncologist.

Telephone interview with the Chief Medical Officer (CMO) at Hospital A on 9/24/19 at 1:40 PM revealed Patient #1 was brought to the ED by EMS after a MVC. Further interview revealed "...an initial visual assessment was performed by the physician [ED Physician #1] in the room and the physician asked the EMS about their thinking of bringing the patient to the ED versus taking the patient to a trauma center...he [ED Physician #1] was just asking the question as to why they would bring the patient to our ED with obvious trauma. He [ED Physician #1] stated the EMS worker said 'if you don't want to see him [Patient #1] I'll take him somewhere else'...the patient was still on the EMS stretcher and they [EMS] wheeled the patient out of the room, placed the patient back in the ambulance and left..." Continued interview revealed "...our expectations would be that all patients who present to our ED or on our campus receive a Medical Screening Examination by a Licensed Medical Provider and those patients to be stabilized, treated, and transferred appropriately. There was no written Medical Screening Examination documented..."

Interview with the ED Nurse Manager at Hospital A on 9/24/19 at 2:10 PM, in the conference room, revealed Patient #1 was brought in by EMS after a MVC and was taken to a room in the ED. Continued interview revealed ED Physician #1 was at the patient's bedside and spoke with EMS. Further interview revealed "...there was discussion between [ED Physician #1] and EMS...why the patient was transported to our ED and not a trauma center. The patient had a cut to his neck and bruising to his chest...EMS made the statement if the physician did not want to see the patient they would take him somewhere else...the patient had never been moved from the EMS stretcher...they [EMS] wheeled the patient out of the room and left our ED..."

Telephone interview with EMS Paramedic #1 on 9/24/19 at 3:30 PM revealed Patient #1 was involved in a single MVC on 9/8/19 and had a laceration to the head and bruising to the chest wall. Continued interview revealed upon arrival at the ED Patient #1 was taken [an ED room]...the physician [ED Physician #1] came into the room and stated 'I don't know why you are here and I am going to transfer him [Patient #1]'...there was no report given. He [Patient #1] remained on our stretcher...we turned around with the patient and took him back to the ambulance and transported the patient to [Hospital B..."

Interview with ED Technician #1 at Hospital A on 9/25/19 at 10:40 AM, in the conference room, revealed Patient #1 was brought to the ED by EMS after a MVC and was taken to a room in the ED. Further interview revealed "...[ED Physician #1] asked EMS why they [EMS] brought the patient to our facility and said the patient would need to be shipped to another facility. He [Patient #1] had a bandage to his neck...a laceration to his neck...the Paramedic said 'I guess you do not want to see the patient'...EMS took the patient out of the room and left the ED..."

Interview with Registered Nurse (RN) #2 at Hospital A on 9/25/19 at 10:50 AM, in the conference room, revealed Patient #1 was brought to a room in the ED by EMS and EMS was talking with ED Physician #1. Further interview revealed "...the physician [ED Physician #1] said to the paramedic 'you know this is serious and he [Patient #1] needs to be transferred.' The patient was still on the EMS stretcher...the paramedic stated ' if you are not going to take care of him we are going to take him somewhere else'...EMS left the ED with the patient...we did not even have time to register the patient..."

Interview with ED Physician #1 at Hospital A on 9/25/19 at 11:10 AM, in ED Room #7, revealed the patient presented to the ED by EMS after he was involved in a motor vehicle accident. The patient had a bandage to his neck and had some active bleeding. Further interview revealed "...I went into the room and I asked the paramedic why they brought the patient here in relation to the patient would need to be transferred to a trauma center. At that time the paramedic stated he would take the patient somewhere else and took the patient out of the room and left the ED..." Further interview revealed "...I got a brief history and looked at the patient at that time but there is no documentation or a medical record for the patient... we [ED Physician #1 and ED Physician #2] did discuss this situation and considered this might be an EMTALA violation..."

Telephone interview with ED Physician #2 at Hospital A on 9/25/19 at 11:30 AM revealed Patient #1 was brought into the ED by EMS and placed into an ED room. Further interview revealed "...[ED Physician #1] came out of the patient's room and told me the EMS had left with the patient prior to a Medical Screening Examination. He [ED Physician #1] stated he had asked them [EMS] why they did not take the patient to the trauma center and told them the patient would need evaluation by the trauma team...EMS left our ED...left our campus with the patient...[ED Physician #1] and I did discuss the situation and agreed the patient did need to have a medical screening examination prior to leaving our ED...there was no documentation of a Medical Screening Examination..."

Interview with the Corporate Director of Risk Management at Hospital A on 9/25/19 at 12:00 PM, in the conference room, revealed an investigation was implemented on 9/10/19 related to Patient #1's presentation to the ED on 9/8/19. Further interview confirmed there was no medical record for Patient #1 and no medical screening examination was completed on Patient #1 for the ED visit on 9/8/19.